Reviews & Research I R e s e a r c h

he pursuit of enhancing one's appearance by whitening teeth is

not a new phenomenon. Reports
of dental professionals using various treatment modalities date back as early as the
1880s' and continue to the present. The
media promotes white teeth as one of the
characteristics of a beautiful smile. With
the ease of access to multiple sources of information, patients are more knowledgeable and inquire more frequently about
the various treatment options available to
help them achieve an ideal smile.
Marilyn Ward, DDS; and Heather Felix, MSc
Dentists can meet their patients' desired outcome through the use of whitenABSTRACT
ingone of the most conservative, effective, and safe esthetic procedures possible.
Numerous teeth whitening systems have
The purpose of this study was to assess the eflicacy of two different BriteSmile* hybeen developed over the past two decades,
drogen peroxide ( H / \ ) gels in a split-arch protocol for whitening teeth in a clinical
but the most common systems today use
setting when used in conjunction with a BriteSmile BS4000 lamp. Fifteen subjects
hydrogen peroxide (H.,), or some prewere enrolled into a single-center clinical trial. The eflScacy of the BriteSmile BS4000
cursor to it, as the active whitening agent.
lamp using both 15% H ^ , and 25% H^^ gel formulations was tested. Study subjects
The factors that determine which whitwere concurrently exposed to the whitening lamp with the 15% H^O^ gel placed on half
ening method to use include: type and
of their anterior teeth and the 25% H^O^ gel on the other half for a total light and gel
intensity of staining; how fast the patient
exposure of 60 minutes. The clinical data collected were shade score, gingival health, and wants the process completed: any existing
dentinal hypersensitivity self-assessment. Changes in tooth shade were better for subtooth sensitivity; willingness to comply
jects exposed to the 25% gel and the dental whitening lamp (average 8.0 shade changes) with various protocols; and the investcompared to subjects exposed to the 15% gel and dental whitening lamp (average 7.6
ment the patient is willing to devote to
shade changes) immediately after treatment. The same held true at the 7-day follow-up
a whiter smile.
(25% gel average 7.4 shade changes versus 15% gel average 73 shade changes). However,
In general, hydrogen peroxide whitens
these differences were not statistically significant. No reports of irritation of gingival .soft
teeth via a two-step oxidative process.^
tissues were documented. The relative changes in mean sensitivity scores were similar
In the first step, the hydrogen peroxide
for both groups with no significant diflerences in mean sensitivity scores between the
molecule is degraded and splits into mulgroups. Both concentrations of H,O^ gel and the whitening lamp combined gave study
tiple components, most often hydroxyl
subjects an average of 8.0 (25% gel) and 7.6 (15% gel) shade changes immediately after
radicals. This occurs spontaneously but
treatment. The 7-day follow-up examination resulted in a regression of lightest to an
can
be a fairly slow process. In most comaverage of 7.4 (25% gel) and 7.3 (15% gel). It was concluded that the use of the chairside
mercial
products, the peroxide product is
whitening light and either 15% or 25% hydrogen peroxide gel is safe and effective for
formulated
such that the peroxide degrawhitening teeth in 1 hour.
dation process is sped up when applied
to the teeth and allowed to interact with
the chemical structure of the teeth and/
or oralfluids,or via a formulated chemical
activation. In the process of degradation,
the peroxide radicals formed react with
stain molecules (chromophores) within
the tooth structure, with the end result
being reduced discoloration of teeth.''
In an attempt to accelerate a satisfactory whitening result, many chairside

A Clinical Evaluation
Comparing Two H2O2 Con
centrations Used with a
Light-Assisted Chairside
Tooth Whitening System

286

c'oMPKNniuM April 2012

Volume 3:!. Number 4

whitening gels are used in conjunction

with a light source."'' When visible light
sources are used, they can react chemically (photocatalyst) within the gel and
potentially allow for a safer and more predictable system compared to heat.''
Light-assisted procedures generally
require only 1 to 2 hours in the clinic to
significantly whiten teeth, whereas takehome products take at least 5 days to
produce similar results.' However, the
trade-off for speed is frequently a higher
per-procedure cost as well as increased
dentinal sensitivity resulting from either nerve irritation due to penetration
of the peroxide into the pulp" or, in some
cases, elevation of pulpal temperatures
due to the heat.'' Because peroxide concentrations vary widely in whitening gels,
the least amount of peroxide needed to
achieve desired results (ie, minimum effective concentration) should be chosen.'"
The objective of this study was to
evaluate the safety and efficacy of a novel
BriteSmile" BS4000 lamp (Philips Discus
Dental, www.philipsoralhealthcare.com)
with two different concentrations of hydrogen peroxide. The null hypotheses
were that there was no difference in shade
change and sensitivity among the evaluated bleach concentrations.
MATERIALS AND METHODS

A total of 15 patients were enrolled

for an in-oflice clinical tooth whitening study performed at a single
dental practice. All subjects signed
an informed consent form adhering to the ethical principles stated
by the World Medical Association's
Declaration of Helsinki." Subjects
were examined before the whitening treatment, immediately after
treatment (same day), and 1 week
after treatment. At each exam,
the following data were collected:
subject demographics and medical
history (pretreatment only); oral
soft-tissue examination; gingival
www.dentalaegis.com/cced

health; shade of maxillary teeth; dentinal hypersensitivity self-assessment; and

complications and adverse events.

Inclusion Criteria
Male and female subjects in good general health and between tbe ages 18 to
80 years at the time of enrollment, with
a tooth shade greater than or equal to A3
for all six nonrestored maxillary anterior
teeth prior to treatment, were included
in the study. Suhjects had to be willing to
not use any other dental whitening product, including toothpaste, throughout
the duration of the study, to refrain from
smoking, and to not consume any coffee,
cola drinks, dark juice, or other drinks or
foods that might stain teeth for 2 hours
after treatment.

the investigator's opinion could interfere

with the assessment of the oral soft/hard
tissue, were excluded, as were subjects
with a history of photosensitivity or suhjects receiving photochemotherapy, systemic antibiotics, anti-inflammatory or
immunosuppressive therapy, or who had
notable intrinsic staining (tetracycline,
fluorosis). Also excluded were those who
had previously used professionally dispensed, take-home, or in-office bleaching
products. Subjects who were unable or
unwilling to complete the study examinations listed herein or who would be relocating or traveling during the course of
the study also were excluded.

Treatment Methods

Subjects meeting the inclusion/exclusion

criteria were treated in the study. The
six maxillary teeth of each subject were
Exclusion Criteria
assessed using the VITA Shade Guide
Subjects with fewer than six anterior
(Vita Zahnfabrick GmbH, www.vitamaxillary teeth and those whose anterior
zahnfabrik.com), and that shade was
maxillary teeth had restorations or denconsidered the qualifying shade for study
tal implants, or those who reported tooth
entrance. On the day of the whitening
sensitivity on maxillary anterior teeth,
treatment, oral soft-tissue examination,
were excluded from the study. Subjects
VITA shade assessment, gingival health,
with a history of sensitivity to peroxides
and dentinal hypersensitivity self-assessor glycols and a documented history of
ment were completed on all six maxillary
untreated caries, recession, abfractions,
anterior teeth.
or cracks on the teeth to be treated, or
All study subjects were treated with
severely malposed anterior teeth also
three 20-minute exposures of the
were excluded. In addition, those with
BriteSmile BS4000 lamp with 15% Up.^
a history of systemic disease, which in
on teeth Nos. 6 through 8, and 25%
HjO^ Of teeth Nos. 9 through II
INTENSITY (COUNTS)
(BriteSmile' Kit, Philips Discus
4000
Dental). The manufacturer's instructions where followed. A lip
retractor and face bib were |)laced,
3000
followed by a light-cured opaque
resin to block all gingival tissue.
2000
Gauze and masking cream were
placed to cover any remaining
1000
oral and adjacent soft tissue. The
^
BriteSmile whitening accelerator
was
applied, along with the bleach600
400
500
300
ing gel, and repeated for a total of
WAVELENGTH (NM)
three individual 20-minulc cycles
for a total exposure time of 60
Fig 1. BrightSmile BS4000 Light-Source Spectrum
April 2012 COMPKNIIUIM

287

Reviews & Research I Research

minutes. After each 20-minute session the

gel was removed by surgical suction and a
fresh layer of gel was applied. During use,
the lamp was positioned using the intraoral optical positioner placed within the
lamp head approximately 5 inches from
the patient's face. The patient's and operator's eyes where protected by filtered
glasses. The BriteSmile BS40()0 light is a
focused, discrete, six-light emittingdiode
(LED) array system with a spectral range
of 400 nm to 505 nm. j\s indicated in the
light-source spectrum in Figure 1, the
BrightSmile HS4000 light is essentially
monochromatic. This light is equivalent
to blue visible light with no significant
other ultraviolet emissions.
Relief ACP gel (0.24 % fiuoride/5%
potassium nitrate, 0.75% amorphous
calcium phosphate) application was completed according to the manufacturer's
instructions. The baseline examination
was conducted immediately after removal of the gel.

removed, and patients were seated in a

position where the teeth in the maxillary
arch were parallel to thefioorduring the
evaluation. Gradations within the valueoriented VITA Shade Guide were utilized
as shown in Figure 2.
Shade change was calculated by determining the change in the number of
shade gtiide units (SGU. difierence in the
absolute numbers of shade guide "step" in
visual evaluation) that occurred toward
the lighter end of the value-oriented list
of shade tabs. Although the scale is not linear in the truest sense, the changes were
treated as representing an ordered series
of relationships for the purpose of analysis.

Fifteen subjects were enrolled in this study:

3 females and 12 males who ranged in age
from 19 to 78, with the average age of .S7
years old. Statistical analysis was performed
to compare shade change and sensitivity
using the Wilcoxon's matched-pair signed
rank test at the 0.05 level of significance.

Tooth Shade Evaluation

Subjects were asked to self-assess sensitivity (without exogenous stimuli) by

recording their perceived sensitivity on
each of the six maxillaiy teeth using a 0 to
10 scale (0 referring to the absence of sensitivity, and 10 to maximum sensitivity),
with the pain definitions shown in Table 1.

Tooth Color Assessment

Sample Size and

Statistical Analysis

RESULTS

Dentina! Hj^iersensitivity
Assessment

Visual color-matching was performed

before whitening, immediately after, and
7 days later. Scores were assessed by two
trained and calibrated examiners in a room
with color-corrected lighting (5,500-K
light bulbs) and under a color-corrected
handheld light (Rite-lite. AdDent. Inc.,
www.addent.com). The shade-matching
distance was 25 cm. The value scale VITA
Classical shade guide (Vita Zahnfabrick
GmbH) was used to determine the best
shade for teeth Nos. 6 through 11. A grey
bib was placed over clothing and the dental light was turned oflF. Any lipstick was

cleaned of all visible plaque with supragingival pumice polish prior to the placement of the bicachinggel. Gingival health
for all patients was monitored but was not
analyzed for the purpose of this study.

Oral Soft Tissue Assessment

Presence of erythema, desquamation,
or ulcration of soft tissues, and gross
changes in teeth or restorations were
documented if present. All teeth were

RELATED CONTENT:
For more information, read Pre-Bieaching Exam
Vital for Optimum Whitening at
dentalaegis.com/go/cced98

Tooth color evaluation and visual color

change according to the VITA Classical
shade guide is reported in Table 2. There
was a significant color change (lightness)
immediately posttreatmcnt {p < 0.01) and 1
weekposttreatment (p < 0.01) using either
15%or25%ll^().,.NosignificantdilfeiviKv
in whitening effects could be detected
when comparing 15% to 25% immediately
posttreatment (p = 0.15) and 1 week posttreatment (p = 0.54).

Dentinal Sensitivity
At baseline (pretreatment), the mean scores
for self-reported dentinal hypersensitivity
weresimilarforsubjectsenrolk'd (Tables).
Patients in the 15% Hp., gi oup reported no
more sensitivity (2.40) than patients in the
25% H.,O., gnuip immediately after treatment (2.40). At 24 hours, the sensitivity for
both groups was reported as 1.33.

FIGURE 2

Value-Oriented VITA Shade Index

Lightest

Vitapan" Classical

Bl

Al

B2

D2

A2

Cl

C2

D4

A3

D3

B3

A3.5

B4

C3

10

11

12

13

14

MPENDIUM April 2012

A4
15

Darkest
C4
16

Volume 33, Number 4

Oral Soft-Tissue,
Gingival Health, and
Sensitivity Evaluation

the investigator. Immediately after treatment, 10 subjects reported a mean score

of 2.40, and after 24 hours, 7 reported a
mean score of 1.33. Five patients reported no sensitivity immediately after, and
eight reported none after 24 hours. All 15
patients were pain-free at 7 days.

DISCUSSION

In-ofTice bleaching procedures using

30% to 35% concentrated, light- or heatactivated 1 \.,O., gels were the most comThere were no reports of erythema, desmon whitening techniques used until
quamation, ulcration of soft tissues, or
thefirst"at-home" nightguard bleaching
any gross changes in teeth or restorations
system was introduced in 1<)8<).'- During
documented at any of the study exams by
the 1960s and 1970s, bleaching protocols
using direct and indirect heat to accelerate the oxidation of the H.,()., were introduced,'"^ but they did not remain popular
because of concerns over possible cervical
Dentinal Hypersensitivity Assessment
rsorption.'"'"Light-and-chemical appliScore
Description
I
cations were introduced in the inid-1990s
0 to 1
No pain = No sens.ation of pain or sensitivity
that made in-office bleaching of vital teeth
more practical.''
2 to 3
Mild pain = Barely perceptible pain or sensitivity
There are inherent safety and efficacy
4 to 6
Moderate pain = Definite perceptible pain, but not excruciating
advantagesto in-office whitening proce7 to 8
Severe pain = Excruciating pain but not constant
dures compared wif h at-home bleaching
9 to 10
Intolerable pain = Excruciating, constant pain
techniques, including dentist supervision, control over soft-tissue exposure
and ingestion of whitening materials,
reduced treatment time, and more immediate results. Today, in-offlce teeth
Mean (SO) Shade Guide Unit (SGU) Measurements and Visual
whitening is arguably one of the most
Shade Guide Unit Color Change (SGUA)
accessible and least invasive cosmetic
(at baseline, immediatelyposttreatment, andl week posttreatment)
dental treatments ofFered by dentists.
Efforts to develop and proviile painless,
25%
I
15%
quick results using peroxide-based, lightHydrogen peroxide
Hydrogen peroxide
activated, laser, or combined therapies
SGU
SGUA
have resulted in the development of new
SGU
SGUA
protocols using lower-concentration gels
10.2
(1.7)
n/a
10.2
(1.7)
n/a
Before treatnnent
that have been shown to be effective in
2.2 (1.5)
8.0
2 6 (1.8)
7.6
Posttreatment
fewer, if not single, visits.'" A consider2.8 (1.8)
74
2.9 (1.8)
73
1 week posttreatnnent
able number of studies evaluating fhe
safety and efficacy of both in-office and
at-home tooth whitening products and
techniques have been conducted and are
ongoing.'" "' A 2009 study by Ontiveros
et al comparingthe use of 25% hydrogen
Mean Dentinal Hypersensitivity Scores
peroxide with and without the addition
15% HjOj
25% H2
of light exposure found a significant dif0.0
0.0
Pretreatment
ference in color achieved after 7 days
for subjects treated with the light.-^ A
2.40
2.40
Day of treatment
review of in-ofiice bleaching has shown
1.33
1.33
24 hours after treatment
conflicting evidence on the effects of
0.0
0.0
7 days after treatment
supplementary light; this can be attribSubjects in both groups had significantly higher scores for hypersensitivity imme- uted to variability with color evaluation,
diately after and 24 hours after treatment, but no differences were found between light specifications, and bleaching product formulations.''
subjects in the 15% or 25% groups.
www.dentalaofiis.coin/cced

April 2012

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Reviews & Research I Researeh

The whitening lamp studied emits visible light, primarily in the near-blue and
visible blue wavelengths (approximately
400 nm to r^05 nm). Thus, despite having a peroxide content that is lower than
many chairside whitening gels, the gel
studied produced significant whitening
with no iatrogenically induced dentinal
sensitivity.
Thffindingsof this study domonsf rate
that the BriteSmile BS4000 dental whitening system is effective at whitening
teeth. This is in agreement with the results of previous studies'"^' that reported
even lower concentrations of peroxide gel
than the 25% and 15% used in this .study.
No significant gingival problems, dentinal
hypersensitivity, or adverse events were
noted during the study, indicating that
the procedure is also quite safe. Patients
in the study reported very mild dentinal
hypersensitivity whether they were exposed to 15% or 25% H.,0., gel. These
data are significant not only because
they demonstrate the effect of a whitening lamp in a controlled clinical trial, but
they also demonstrate that a whitening
lamp emitting visible light is safe and effective for dental whitening when used
as directed. If blocking of the gingival
and other oral soft tissues is properly
performed, these data indicate that this
system can be used to whiten teeth without fearing radiant heating of the teeth,
which could raise pulpal temperature and
lead to iatrogenic tooth damage.
Light activation of whitening gels has
been debated within dentistry for quite
some time. Manufacturers of light products have made various claims that whitening of vital teeth can be aided by the
use of lamps emitting visible, ultraviolet,
or infrared radiation (heat) and lasers.
Invariably, these claims are disputed by
whitening gel companies or by dental
researchers who assert that the lamps
are not needed and vital tooth bleaching
is simply a result of applying hydrogen
peroxide to teeth for a sufficient amount
of time. While there may be little or no
290

COMI'KNDIIIM April 2012

risk to subjects when using lamps that

emit only visible light, there is not much
data to demonstrate that visible light has
any discernible effect on whitening gels.
Hydrogen peroxide by itself that lacks fentonic or similar constituents is not easily
light-activated, ie, it does not liberate free
radicals that can be used to attack chromophorcs, unless it is exposed with light
having a wavelength of approximately 365
nm-' or less. The application of direct heat
could accelerate the reactivity of a bleaching agent and shorten the treatment time.
However, the heat alone generated from
bleaching lights only provides for a minimal decomposition of peroxide products.-"
The system used in this study emits visible
light in the blue range of approximately
400 nm to 505 nm. Further studies comparing this system with bleaching gel alone
and other lights with different spectral
outputs are needed to understand the full
efi'ect of thelight itself.

Marilyn Ward. DDS

CONCLUSION

Heather Felix, MSc

The 7-day follow-up examination resulted

in a regression of lightness to an average
of 7.4 (25% gel) and 7.3 (15% gel). Selfreported hypersensitivity was mild and
no higher for either group, and resolved
after 24 hours. There were no reports of
gingival irritation.
Within the limitations of this study,
the null hypotheses wore confirmed and
it was concluded that the BrightSmile
light-activated, in-ofiice whitening system used with either 15% or 25% H.,.,gel
is safe and equally effective for whiteni ng
teeth in f hour.
DISCLOSURE

This study was funded by Discus Dental,

LLC. a Philips Oral Healthcare Company.
ABOUT THE AUTHORS

'rivale Practice. Houston. Texas

Director of Research. Philips Di.scus Dcntul. Inc.

The study data demonstrate that a lightcatalyzed gel with a concentration of

15% to 25% H.p, is safe and effective for
whitening vital maxillary teeth an average of approximately eight shades in one
60-minute session of light activation.
Changes in tooth shade were directionally better for the subjects exposed to the
25% gel and the dental whitening lamp
(average 8.0 shade changes) compared to
subjects exposed to the 15% gel and dental
whitening lamp (average 7.6 shade changes) immediately after treatment and at
the 7-day follow-up (25% gel average 7.4
shade changes versus 15% gel average 7.3
shade changes). I Iowever, the differences
observed were not statistically significant.

RELATED CONTENT:
Learn more about shade matching at
dentalaegis.com/go/ccedgg

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